The importance of a continuum of care before, during and after pregnancy in women with type 1 and type 2 diabetes along the Irish Atlantic seaboard
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Pregestational diabetes is the most common chronic medical condition to complicate pregnancy and is associated with an increased risk of morbidity and mortality for the mother-offspring pair. Optimising outcomes for this population is an important public health issue and requires the identification of modifiable determinants of risk and the provision of high quality clinical care. My thesis addresses the importance of a continuum of care before, during and after pregnancy for women with type 1 and type 2 diabetes. In this thesis, I firstly report pregnancy outcomes for a regional cohort of women with pregestational diabetes in the West of Ireland over a decade, and examine in detail the issues of gestational weight gain (GWG) and diabetic retinopathy. Employing a number of different methodological and statistical approaches, I outline the clinical and economic benefits of a regional approach to prepregnancy care for women with diabetes. Next, I describe a protocol for developing a core outcome set (COS) for studies evaluating prepregnancy care for women with pregestational diabetes, and report the study results and the final COS. Finally, I examine women at 12 months post-partum to assess the impact of pregnancy and prepregnancy care on longer-term treatment goals in women with diabetes. The work of this thesis enhances existing knowledge on the subject of pregestational diabetes. It provides up-to-date, regional data on pregnancy outcomes and identifies excessive GWG as an independent risk factor for adverse outcomes. This is the first piece of work to outline both the clinical and economic benefits of a regional prepregnancy care programme. The thesis identifies a need for a paradigm change in the way post-partum care is delivered to women with diabetes. A COS for studies evaluating prepregnancy care is now available and it is anticipated that it will stimulate further high-quality research in this area.